Canadian health agencies are investigating a spike in confirmed cases of infant botulism across the country. Between January and April, three babies in Ontario, two in British Columbia and one in Alberta suffered from the rare but potentially fatal form of food poisoning. It’s a worrying trend, since there were no cases reported in Canada last year, according to the Public Health Agency of Canada. Typically, about two cases are reported per year, although seven were identified in 2015.

The Public Health Agency of Canada said they have not identified the cause of the recent cases, but officials are looking for possible common exposures.

“To date, none of the food samples tested have been positive for botulism,” said Dr. Vinita Dubey, associate medical officer of health for Toronto Public Health. “Collecting a thorough history from the parent on anything consumed or put in the mouth by the infant is an important part of the investigation.”

One known and avoidable cause of infant botulism is honey — both raw and pasteurized. Although the natural sweetener is sometimes used on soothers, as a natural cough suppressant or to replace sugar in homemade baby food, doctors recommend that parents keep honey away from children under the age of one. Here’s everything you need to know about infant botulism and honey.

What is infant botulism and what causes it?

It’s a rare illness caused by food contaminated with Clostridium botulinum bacteria. The spores colonize and grow in the infant’s large intestine and produce a neurotoxin. It only affects infants because adults and children more than 12 months old have more good bacteria in their gut that can help to quickly move the botulism bacteria spores through their gastrointestinal system before it has time to grow and release the toxin. Botulism can also occur in adults who have altered gut flora or if the toxin has already been produced on contaminated food. The bacteria can also be inhaled or enter through open wounds.

What are the symptoms?

Paralysis is characteristic of infant botulism, so symptoms tend to revolve around a lack of muscle strength and movement. The earliest signs include difficulty feeding, weak sucking, trouble swallowing and increased drooling. The baby may also make fewer facial expressions and have a different cry or trouble breathing. From there, the baby will become increasingly weak or “floppy.” Although constipation is one of the most common signs, it may be overlooked as it’s also a symptom for many other illnesses. Symptoms usually start to appear between six and 36 hours after ingesting contaminated food or drink, but it can take up to 10 days.

Why is honey so bad for infants?

Botulism spores can be carried into a bee hive on dust, dirt or pollen and contaminate the honey. Pasteurization cannot reliably kill the bacteria, and while that’s no problem for adults and older children, who can digest the bacteria before it does any harm, babies under 12 months cannot. Even a little taste of honey is enough to make a baby sick. While most cases of infant botulism are not caused by honey — only three of the 42 cases reported in Canada between 1979 and 2013 were linked to the sweet stuff — it is the only avoidable source of exposure to the bacteria.

Other sources

The bacteria can be present in improperly canned or fermented foods, but people can also inhale botulism spores or ingest them when they come into contact with contaminated dirt. This makes it extremely difficult to identify avoidable sources other than honey or contaminated food. “It’s just in the environment or dust,” explained Bryna Warshawsky, the medical director of communicable disease at Public Health Ontario. “About 15 to 20 per cent comes from honey, the rest they don’t really have a source.”

Can it be treated?

There’s no public vaccine for infant botulism, but it can be treated. Babies should be taken to a doctor as soon as possible so they can receive an antitoxin. They may also require a respiratory aid or a feeding tube. Stool samples are important for doctors to analyze to identify the toxin.

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